Patient had undergone a hysterectomy on January 4 and was discharged on January 5. She had abdominal and left sided flank pain over the weekend and notified her gynecologist on the Monday, January 7. He saw her in his office on January 8. His office note reflects that she had left sided pain, was unable to eat or drink without having pain and that she was unable to lift leg due to severe pain. He provided a script for a stat abdominal/pelvic CT. He noted a concern for possible ureter issue or possible clot.
Patient left his office and presented to the emergency room on that same day. A abdominal/pelvic CT scan with contrast was performed and was interpreted as showing mild left hydroureternephrosis. The BUN was 10 (ref range: 5 - 22) and the Creatinine was 1.2 with normal lab reference range of .5 - 1.7. The ED PA called the gynecologist with the CT and lab results. The gynecologist stated that the findings were common due to inflammation post surgery and that she was safe for discharge and follow up in 1 week.
Patient followed up with PCP the following day and was seen by ARNP. She informed ARNP of the ED visit and call to gynecologist. ARNP told her to keep appointment with gynecologist and also gave a referral to a nephrologist. Patient's pain resolved by the time she saw her gynecologist a week later.
Patient seen by nephrologist on January 24. He counseled her to stop the Naproxen that she had been taking since the ED visit. He ordered a nuclear medicine renal scan and labs including a 24 hour urine. The scan was completed on January 31 and was found to be consistent with severe left obstructive uropathy with essentially no excretory function of the left kidney. The possibility of left renal vein thrombosis was felt to be in the differential. The labs showed a creatinine level of 1.15 with a normal lab reference range of .4 - 1.10. The nephrologist referred the patient to a urologist.
The urologist saw the patient on February 4. He noted that there was nonvisualization of activity reaching the left kidney on the flow acquisition with essentially a flat renogram curve with only late cortical activity. No excretory function seen. He asked the patient to obtain the CT images that were completed on January 8 for his review. The patient obtained the images the following day. Although there are no further notes in the urologist's chart, the patient recalls the urologist calling her on February 7 and informing her that her kidney failure was due to a "vascular issue" during her hysterectomy and that there was nothing that could be done to save the kidney. He took no further action.
The patient returned to the nephrologist on February 26. He noted that the urologist felt the kidney was most likely nonfunctional and had been concerned about the possibility of left renal vein thrombosis. The nephrologist ordered a Renal artery Duplex.
The renal artery duplex was completed on March 27 and was interpreted as showing no renal artery stenosis. No flow was obtained in the left renal vein but there was felt to be collateral venous flow. A 2.16 cm hydroureter was identified.
The nephrologist subsequently referred the patient to IR in March. IR suggested the presence of nutcracker syndrome and no intervention was taken. The last CT abdomen and Pelvis taken without contrast was completed on September of that same year. A severe left hydroureter with moderate hydronephrosis was identified.
The nephrologist continued to follow the patient for the next year and a half. No action taken with regards to the left kidney.
I am seeking input related to standard of care and causation specific to the nephrologist.
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Do you believe there might have been medical error?
Kidney dysfunction post-hysterectomy should be assumed to be due to ureteral injury. Appropriate management (by a urologist, not the nephrologist) should lead to normal kidney function on the affected side. The diagnosis was made by the nuclear study but attention to "vascular" issues instead of defining the urinary tract distracted from the correct diagnosis. Even when hydronephrosis was identified, referral to a urologist to address the situation did not happen. Even weeks after the procedure, a significant return of kidney function would be expected. The appropriate procedure, depending on the site of the ureteral injury would be either construction of an ileal ureter (use a loop of bowel as a new ureter) or do auto-transplant, meaning remove the kidney and place it in the patient's pelvis, connected to the bladder with the native ureter.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The hysterectomy led to a ureteral injury. The correct diagnosis was not made. When it was made by the demonstration of hydronephrosis and/or hydroureter the correct procedure was not performed. The gyn, the urologist and the nephrologist are all responsible for this egregious course.
What makes you a good expert for this case?
Much experience with obstructive uropathy. I work closely with urologists.
How often do you encounter cases similar to this one in your practice?
Fortunately not! Some experience as an expert in a couple of cases.
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